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Renal Disorder/Failure Case Study - Question 1

The symptoms suggest that the patient might be suffering from a chronic kidney disorder – uremia. According to Hickey et al. (2019), uremia is a chronic condition in which the kidney is not able to filter out the wastes from the body and presents symptoms like nausea, vomiting, and lethargy. There is excessive urea in the blood and pruritus or itch is one of the common issues for the individual suffering from chronic renal failure/disorder. It causes lethargy as there is a build-up of impurities and toxins inside the body that makes the patient feel tired with a sense of weakness. In kidney disorder, the extra sodium and fluid in the circulation can cause edema in the lower extremities.

Renal Disorder/Failure Case Study - Question 2

According to Luciani et al. (2019), the S4 signifies the fourth heart sound, due to scar tissue formation, there is an increase in stiffness of the left ventricle of the heart, and thus resulting in the production of the fourth heart sound S4. It is also called as atrial gallop and is a sign of diastolic heart failure or other hypertensive heart diseases. The cardiac findings that are expected to be observed in hypertensive conditions are: an abnormal heart sound S4, sustained apical impulse, apical impulse low and out, and loud A2 component over the aortic area. In this condition, the ventricle walls get thick to reduce the heart’s work pressure that results in unexpected outcomes.

Renal Disorder/Failure Case Study - Question 3

The possibilities of the 2+ lower extremity oedema are – water retention from renal failure, hypoalbuminemia, and congestive heart failure. The patient is showing an abnormal S4 heart sound that confirms that he is having heart-related issues and his pruritus also confirms that due to renal failure/disorder the increased fluid inside the body led to oedema at his extremities. According to Gupta et al. (2016), in patients with renal failure/disorder or uremia, there is increased degradation and reduced synthesis of albumin. This results in low albumin levels and increased inflammatory responses leading to hypoalbuminemia. As the patient’s heart rate is high, shows oedema, lethargy, vomiting, and nausea, all these show that he might have hypoalbuminemia that leads to a possibility for his lower extremity oedema.

Renal Disorder/Failure Case Study - Question 4

The patient shows the signs of itching or pruritus and the significance of the finding ‘superficial excoriations of his skin from scratching’ is – it confirms that the patient feels the urge to itch. According to Rizk et al. (2018), the urge to itch or pruritus is commonly observed, so it can be an indicating factor that the patient is having renal failure or chronic kidney failure disease. In the case of chronic renal failure, uremic pruritus takes place and that is known as chronic kidney disease-associated pruritus (CKD-associated pruritus).

Renal Disorder/Failure Case Study - Question 5

A renal ultrasound was ordered because the patient show symptoms that are very much familiar with renal failure or related health complications like uremia. Moreover, to study about his kidney a renal ultrasound was ordered. A patient with such signs is asked by the health professionals to get their renal ultrasound as soon as possible to detect the related health complications if any. According to Kuo et al. (2019), kidney ultrasound provides information about the shape, location, and size of the kidney, bladder, and ureters. It can detect fluid collection, infection, tumors, cysts, abscesses, and obstructions in or around the kidney region. This also provides useful insights about the kidney functions and its abnormalities by evaluating and monitoring the amount of blood filtered by it.

Renal Disorder/Failure Case Study - Question 6

The patient is having a small kidney that can indicate to a point that there is an issue of kidney atrophy or ineffective kidney function. According to Narasimhamurthy et al. (2017), a patient with a small kidney indicates the condition of kidney failure at later stages as the kidney is unable to filter out the waste or toxins. However, the normal size of the kidney is – mean average length from pole-to-pole 10-13 cm. In general, the right kidney is slightly smaller than the left kidney. In this case, the kidney size is not normal for the patient, as it is small in size. A small kidney size signifies that the kidney is not able to work effectively as a normal kidney and this can lead to other health complications like kidney failure or high blood pressure. However, a large kidney size signifies a condition of hydronephrosis – welling in the kidney. This occurs if there is a blockage or obstruction in kidney as a result of which the kidney cannot function properly and there is a build-up of urine inside it.

Renal Disorder/Failure Case Study - Question 7

In a renal ultrasound, the evidence that suggests obstruction is - dilated ureter, large kidney, and dilated calyces. According to Jokinen & Seely (2017), a dilated ureter often occurs due to a blood clot or an obstruction of kidney stones, resulting in a blocked pathway as a result the ureter get dilated with blocked urine. Whenever the urine cannot pass out from the kidney, it gets blocked in the kidney resulting in large kidney size. This evidences show that there is some blockage or obstruction in the kidney. Moreover, dilated calyces also suggest that the urine is not passing out due to some obstructions inside the kidney and its pathways.

Renal Disorder/Failure Case Study - Question 8

The patient is having chronic renal failure. The patient shows a creatinine level of 16mg/dl, blood urea nitrogen (BUN) with 170mg/dl, and hemoglobin of 8.6 gm/dl. According to Hickey et al. (2019), the normal creatinine values are 0.7-1.5 mg/dl if there is a chronic renal failure then the creatinine levels will rise in the blood. During chronic kidney failure, the bone marrow makes fewer red blood cells so less oxygen is available ton cells and the patient suffers from anemia resulting in reduced hemoglobin. A normal BUN level is 7-22 mg/dl, but an elevated BUN level shows that due to either dehydration or heart failure the kidney is not getting enough blood flow, therefore, the BUN levels in blood rises. Moreover, the poor calcium levels of 7.2 shows that calcium is getting deposited in bones and other tissues resulting in low serum calcium levels. The normal values ate 8.9-10.3 mg/dl (Kuo et al., 2019).

Renal Disorder/Failure Case Study - Question 9

GFR stands for glomerular filtration rate. It tells about the amount of blood that passes through kidneys per minute and it also gives information about the effectiveness with which the kidney s working. The normal values are 60 ml/min. or higher and a GFR of values below 6o indicates kidney disease (Thomson et al., 2016). The calculated GFR, in this case, is 6.6 ml/min.

Patient’s age – 41

Patient’s weight - 76.5 kg

Creatinine level – 16 mg/dl

(140 and 72 are constants in the formula)

140-41 (76.5 kg) = 6.6 ml/min
72 x 16.0

Renal Disorder/Failure Case Study - Question 10

The calculated GFR in this case if the candidate was a female is 5.6 ml/min. the values are lower in the case of females because men have higher creatinine generation rate and higher muscle mass. Age and sex affect the values of the glomerular filtration rate (Iddrisu et al., 2020). 

Renal Disorder/Failure Case Study - Question 11

The 24-hour urine protein excretion in this patient is 5,100 mg. According to Dhondup & Kian (2017), a patient with high protein in urine is often considered as a sign of kidney damage. The kidneys are not allowed to pass through a high amount of protein through them but if the amount of protein like albumin or others is high in urine then it is an indication that the kidney is damaged or injured that is leading to more protein content in the urine. However, a temporary rise of protein in urine cannot be considered as kidney damage.

Renal Disorder/Failure Case Study - Question 12

Yes, this amount of urine produced by this patient, in this case, is adequate as it lies in the normal range. According to Iddrisu et al. (2020), the normal values are 800-2000 ml per day. Many issues can lead to a less/decreased amount of urine per day in males like reduced fluid intake, dehydration, or other chronic kidney-related health problems.

Renal Disorder/Failure Case Study - Question 13

According to Dhondup & Kian (2017), the method of collection has 2 main points to keep in mind: it is necessary to discard the first-morning void, and the rest of the voids should be maintained or stored in the container. The container should be stored at cool temperatures until the sample is transferred to the lab for testing.

The appropriate time for this test can be any time after the patient urinates during the day. However, as per the instruction of the healthcare professional, the patient can start the test but mostly the test is started in the morning time and the urine for the next 24 hours is collected in the container.

Renal Disorder/Failure Case Study - Question 14

The measured GFR is:

24-hour urine and creatinine - volume 850 ml and creatinine 180 mg/dl

Patient’s creatinine level – 16.0 mg/dl

 180 mg/dl x 850 ml/1440 min) = 6.6 ml/min
16.0 mg/dl

According to Rizk et al. (2018), the glomerular filtration rate is measured to get information about the following things: detection of chronic kidney failure (CKD) progression, decision making about the treatment plans or diagnosis, understanding the category or stages of the disease, and detection of the kidney disorders. It also provides other information like if GFR is reduced it means there is a renal disease, number of functioning nephrons, and many others.

Renal Disorder/Failure Case Study - Question 15

In this case, the parathyroid hormone is elevated because there is decreased excretion of phosphate due to the decrease in GFR. According to Shariaty et al. (2017), in chronic kidney failure, the parathyroid gland is enlarged resulting in increased secretion of parathyroid hormone which in turn disturbs the homeostasis of calcium, vitamin D, and phosphorus levels. As the damaged kidney cannot convert vitamin D to its active form and also cannot excrete phosphate. This ultimately removes calcium from the circulation and insoluble calcium phosphate is formed in the body.

Renal Disorder/Failure Case Study - Question 16

The most likely cause of this patient’s anemia is the decreased erythropoietin. According to Srinivasan et al. (2016), if the patient suffers from renal disorders, then his/her kidney is unable to make sufficient levels of erythropoietin. This reduced levels of erythropoietin in the body lead to reduced numbers of red blood cells (RBCs) inside the body. This means the development of a condition called anemia that makes the patient weak and lethargy. A reduced level of red blood cells inside the body can cause many health-related complications as the cells get reduced levels of oxygen. This anemia is also associated with low hemoglobin levels during kidney failure health issues in the patient.

Renal Disorder/Failure Case Study - Question 17

Yes, this patient should be started on dialysis as these signs and symptoms show that his condition is very critical. According to Luciani et al. (2019), dialysis is provided if the patient is having chronic kidney failure, but this system keeps the body in balance. Dialysis does the following function: help in controlling the blood pressure, maintain the levels of certain chemicals inside the body, removal of salts, waste, and extra water to prevent the conditions of oedema. This facility is provided in the hospital to the patient or at home.

The indications of dialysis, in this case, are lethargy, oedema, poor appetite, nausea, vomiting, low glomerular filtration rate, and severe metabolic acidosis. There are many other factors like volume overload, uremia, a disturbed balance of electrolytes, abnormalities in acid-base, and dialyzable toxins. These factors will be kept in consideration during his dialysis therapy.

Renal Disorder/Failure Case Study - Question 18

The most likely diagnosis for his renal disease is diabetes and the patient already had a long history of diabetes and hypertension. This patient also shows high protein levels in his urine, thereby indicating that he is a patient of proteinuria. According to Iddrisu et al. (2020), proteinuria is a clear marker that kidney disease is progressing and it’s also a sign for increased morbidity and mortality. High blood glucose can damage the blood vessels in kidney and hypertension is also very common in diabetes that adds to the severity of the disease. So, together with diabetes and hypertension, proteinuria will cause the severity of the condition.

References for Renal Disorder/Failure Case Study

Dhondup, T., & Qian, Q. (2017). Electrolyte and acid-base disorders in chronic kidney disease and end-stage kidney failure. Blood Purification43(1-3), 179-188. https://doi.org/10.1159/000452725

Gupta, A., Palassery, R., Ahuja, S., Egler, R., & Matloub, Y. (2016). Eltrombopag eliminates transfusion requirements in a patient with Fanconi anemia. Biology of Blood and Marrow Transplantation22(3), S245-S246. https://doi.org/10.1016/B978-0-12-391448-4.00012-5

Hickey, N. A., Shalamanova, L., Whitehead, K. A., Dempsey-Hibbert, N., van der Gast, C., & Taylor, R. L. (2020). Exploring the putative interactions between chronic kidney disease and chronic periodontitis. Critical Reviews in Microbiology46(1), 61-77. https://doi.org/10.1080/1040841X.2020.1724872

Iddrisu, M. A., Senadjki, A., Mohd, S., Yip, C. Y., & Lau, L. S. (2020). The impact of HPB on elderly diseases (diabetes mellitus, hypertension, hypercholesterolemia, minor stroke, kidney failure and heart problem): A logistic analysis. Ageing International, 1-32. https://doi.org/10.1007/s12126-020-09368-9

Jokinen, M. P., & Seely, J. C. (2018). Urinary bladder, ureter, and urethra. Boorman's Pathology of the Rat (pp. 167-188). Academic Press. https://doi.org/10.1016/j.bbmt.2015.11.664

Kuo, C. C., Chang, C. M., Liu, K. T., Lin, W. K., Chiang, H. Y., Chung, C. W., & Chen, K. T. (2019). Automation of the kidney function prediction and classification through ultrasound-based kidney imaging using deep learning. NPJ Digital Medicine2(1), 1-9. https://doi.org/10.1038/s41746-019-0104-2

Luciani, M., Saccocci, M., Kuwata, S., Cesarovic, N., Lipiski, M., Arand, P., & Zuber, M. (2019). Reintroducing heart sounds for early detection of acute myocardial ischemia in a porcine model-correlation of acoustic cardiography with gold standard of pressure-volume analysis. Frontiers in Physiology10, 1090.

Narasimhamurthy, M., Smith, L. M., Machan, J. T., Reinert, S. E., Gohh, R. Y., Dworkin, L. D., & Hu, S. L. (2017). Does size matter? Kidney transplant donor size determines kidney function among living donors. Clinical Kidney Journal10(1), 116-123. https://doi.org/10.1093/ckj/sfw097

Rizk, D. V., Meier, D., Sandoval, R. M., Chacana, T., Reilly, E. S., Seegmiller, J. C., & Molitoris, B. A. (2018). A novel method for rapid bedside measurement of GFR. Journal of the American Society of Nephrology29(6), 1609-1613. https://doi.org/10.1016/j.biopha.2016.04.041

Shariaty, Z., Shan, G. R. M., Farajollahi, M., Amerian, M., & Pour, N. B. (2017). The effects of probiotic supplement on hemoglobin in chronic renal failure patients under hemodialysis: A randomized clinical trial. Journal of Research in Medical Sciences: The Official Journal of Isfahan University of Medical Sciences22. https://dx.doi.org/10.4103%2Fjrms.JRMS_614_16

Srinivasan, R., Fredy, I. C., Chandrashekar, S., Saravanan, J., Mohanta, G. P., & Manna, P. K. (2016). Assessment of erythropoietin for treatment of anemia in chronic kidney failure-ESRD patients. Biomedicine & Pharmacotherapy82, 44-48. https://doi.org/10.1681/ASN.2018020160

Thomson, H. J., Ekinci, E. I., Radcliffe, N. J., Seah, J. M., MacIsaac, R. J., Jerums, G., & Premaratne, E. (2016). Elevated baseline glomerular filtration rate (GFR) is independently associated with a more rapid decline in renal function of patients with type 1 diabetes. Journal of Diabetes and its Complications30(2), 256-261. https://doi.org/10.1016/j.jdiacomp.2015.11.003

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